Psychiatry · Easy
This case is fictional and exists for study. It describes no real patient.
24 years · female
A 24-year-old female presents to her general practitioner complaining of recurrent, sudden-onset episodes of intense fear. During these episodes, she experiences rapid heart palpitations, shortness of breath, trembling, profuse sweating, and a feeling that she might die. The episodes peak within 10 minutes and resolve spontaneously within 30 minutes. She has experienced four such episodes over the past month. Between attacks, she experiences constant apprehension about having another episode and has begun avoiding crowded places. Physical examination and baseline investigations, including an electrocardiogram and blood tests, show no organic abnormalities.
Vital signs
- HR
- 74 bpm
- BP
- 118/76 mmHg
- RR
- 14/min
- Temp
- 36.6 °C
- SpO₂
- 99%
Examination findings
- Chest clear to auscultation bilaterally
- Normal S1 and S2, no murmurs
- Neurological examination completely intact
Investigations
| Thyroid Stimulating Hormone (TSH) | 2.1 mIU/L | reference: 0.4-4.0 |
| 12-lead ECG | Normal sinus rhythm N/A | reference: Normal sinus rhythm |
Question 1 of 3
What is the most likely diagnosis?
Panic disorder is characterized by recurrent, unexpected panic attacks that peak within minutes, accompanied by persistent apprehension about future attacks or their consequences. Generalized anxiety disorder features chronic, persistent worry across multiple domains for at least 6 months. Phobic anxiety disorder is triggered exclusively by specific situations or objects. Acute stress reaction occurs immediately following a discrete, catastrophic stressor.
Teaching point: Panic disorder is defined by recurrent, unexpected panic attacks accompanied by persistent concern about future attacks.
Question 2 of 3
Which of the following is the most appropriate first-line long-term management strategy for this patient?
NICE guidelines recommend either Cognitive Behavioural Therapy (CBT) or an SSRI (such as sertraline) as first-line interventions for long-term management of panic disorder. Long-term benzodiazepines like diazepam are contraindicated due to the risk of dependence and tolerance. Beta-blockers like propranolol may reduce somatic symptoms of performance anxiety but are not first-line for panic disorder. Antipsychotics like haloperidol are inappropriate for anxiety disorders.
Teaching point: First-line long-term management for panic disorder includes Cognitive Behavioural Therapy (CBT) or an SSRI.
Question 3 of 3
The patient asks for advice on what to do if she begins to experience a panic attack at home. What is the single most appropriate self-management advice?
Controlled slow breathing exercises help counteract hyperventilation, and remaining in the situation promotes habituation, breaking the cycle of panic. Paper bag rebreathing is no longer recommended due to safety concerns (e.g., risk of severe hypoxia if misdiagnosed). Routine PRN benzodiazepine use for mild attacks carries dependence risks. Emergency ambulance activation is unnecessary once organic causes have been thoroughly ruled out.
Teaching point: During an acute panic attack, patients should be encouraged to practice controlled breathing and remain in the situation to facilitate anxiety habituation.
Key learning points
- Panic disorder involves recurrent, unexpected panic attacks followed by persistent fear of future attacks.
- Organic mimics such as hyperthyroidism and cardiac arrhythmias should be ruled out with targeted tests before making a primary psychiatric diagnosis.
- First-line treatments for panic disorder are Cognitive Behavioural Therapy (CBT) or SSRIs, whereas long-term benzodiazepine use should be avoided.
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